Other Participating Organisations / Businesses / Groups

Clare & Gilbert Valleys Council /
APPLICATION FORM -
Form Name: / Event Application Form / Document Number:
Form Owner: / ManagerGovernance & Community Services
Required Notification Periods
Event Application Form / Council requires a minimum of 4 weeksnotice. If your event will be regular or recurring, you will require a Local Facility Hire Form. Please contact Council.
Temporary Structures / Council can require 4 months notice for applications for temporary structures.
Road Closures (Council Road) / Council requires a minimum of 3 monthsnoticewhere events impact on roads and road reserves.
Sale of Food & Amenities / Council requires a minimum of 4 weeksnoticefor health and hygiene requirements relating to food and amenities.
Signage / Council requires a minimum of 4 weeksnotice

Venue

Venue Name:
Venue Location:

Event Description

Event Title
Event Description
Provide detail of usage of venue

Event Organiser Details

Contact Person for Event
Organisation
Address
Phone / Mobile / Email

Event Details

Event date(s) / Start / Finish
Event time(s) / Start / Finish
Number of Days
Venue Preparation / Start date / Time
Vacated date / Time
Arrangements for Site Clean up: / Details:
Estimated daily attendance / Estimated overall attendance
(for events longer than 1 day)

Other Participating Organisations / businesses / groups

Are there any organisations businesses / groups apart from the event organiser involved / Yes / No / Details
Insurance / Council requires evidence of public liability insurance for food and alcohol providers, amusement device providers and any other high risk event participants.
Other types of low risk participants can be managed by the event organiser. The event organiser is to ensure that if participants do not hold their own public liability insurance, that the event organiser’s public liability insurance covers each event participant.
Marquees and Structures / The pegging of any marquee or structure is prohibited due to the existence of underground services at many facilities. Please discuss your requirements with Council.
Signage / Promotional signage larger than 2m² or with lights/flashing/moving parts or erected for longer than 4 weeks is prohibited. Signage must not be erected earlier than 1 month prior to event and must be removed 1week after the event. Please discuss other requirements with Council.
Pyrotechnics / Pyrotechnic displays are not permitted.
Inspections / Pre and post event inspections may be carried out at Council’s discretion

Site Plan

Detail location of facilities and activities of the event on the grid provided below or attach own site plan.
The following points are a guide only of what should be included on the site plan:

Access and egress points for vehicles and people
Activities/entertainment areas
Camping areas
Emergency services
First aid posts
Road Closures

Food stalls
Any identified hazards
Parking
Public telephones
Restricted or prohibited areas
Toilets

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Event Insurance

If your event is being held on behalf of an organisation, please provide your organisations: / Policy Number / Expiry Date
Public Liability Insurance (Minimum $10 million) Certificate of Currency to be provided
If your event includes other participants, such as food or alcohol, amusement devise, craft stallholders or entertainment providers you are required to ensure that each participant is covered by their own public liability insurance or that your public liability insurance provided covers the participants. The signing of this event application form documents your agreement to this condition. / //

Traffic Management and Road Closures

Will the event impact on local traffic access, flows or speed or will it be necessary to close any roads or divert any traffic for your event?
Yes - you will need to provide a Traffic Management Planwithin 4 Months prior to the Event. Attach further details as required.
No – go to Section 8.
Who has been engaged to implement your traffic management plan? / Organisation
Contact Name / Contact Number
Event Day Contact Name / Event Day Contact Number
Workzone Traffic Management Certification Number / SAPOL Training Certificate Details
What signage is required (for example Road Closure, Community Event, Stop Go signage, 25km)?
Name of Road/Street
Between Road at start of closure / And Road at end of Closure
Start Date / / / / Start Time
Finish Date / / / / Finish Time
Between Road at start of closure / / / / Finish Time
Name of Road/Street
Between Road at start of closure / And Road at end of Closure
Start Date / / / / Start Time
Finish Date / / / / Finish Time
Between Road at start of closure / / / / Finish Time

Alcohol

Is alcohol for sale? Where alcohol is to be sold, supplied or consumed, you may be required to obtain a Limited Liquor Licence under the Liquor Licensing Act 1997.
Refer to Consumer and Business Services (CBS) or phone 131 882 for further details.
Yes – Please supply alcohol provider details below and organise a Limited Licence from CBS. Applications to be submitted at least 14 days prior to an event.
Licence number to be supplied to Council.
No
Do you need a supporting letter from Council for your liquor licence application Yes No
Are you providing alcohol for consumption purposes only (not for sale)?
Yes - you may need to obtain a Limited Licence from CBS. Applications to be submitted at least 14 days prior to event.
If issued with a licence, please supply alcohol provider details and licence numberto Council.
No – go to Section 9
Alcohol Provider / Contact Name / Contact Number / Producer Licence or Limited Licence Number / How will alcohol be served and managed? / How many people do you expect in the licenced area at any one time? / Public Liability Insurance
Expiry Date
/ /
/ /
/ /
/ /

Food

Will food be sold / served / offered at your event?
Yes – Please supply food provider details below and ensure the food provider/s advise of their Food Business Notification Number (FBN)
or complete a Temporary Food Business-Premises Small Application Form.doc if located outside Clare & Gilbert Valleys Council area. FBN or temporary application form to be supplied to Council.
No – go to Section 10.
Supplier/Caterer/Food Business Name / Type of Supply - food/ beverage / Food Business Notification Number or Form Attached? / Public Liability Insurance Number and Expiry Date / Contact Details
Food / FBN:
(or application for FBN or Temporary FBN attached) / / / / Name
Address
Beverage
Email
Phone
Food / FBN:
(or application for FBN or Temporary FBN attached) / / / / Name
Address
Beverage
Email
Phone
Food / FBN:
(or application for FBN or Temporary FBN attached) / / / / Name
Address
Beverage
Email
Phone

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Amusement Devices (including inflatable structures)

Will there be amusement devices operating at the event?
No – go to Section 11.
Yes –Please provide details below: Public Liability Insurance Policy Number to be supplied to Council.
Proprietor / Structure type and platform height / SafeWork SA Certificate of Registration Number / Public Liability Insurance Number and Expiry Date / Annual Inspection Certificate
/ /
/ /
/ /
Note:

Interstate registrations are not acceptable in South Australia.
SafeWork SA requires Event Organisers to check the SafeWork SA Certificate of Registration Number against the equipment plate on the day of the event.
Annual Inspection Certificate only required for devises with platform height of over 3 metres

Council Assistance – Community Not-for-profit Events Only

Waste Management –
Would you like Council to supply bins?
Note: There will be additional charge of $10 per 140L bin / Red Waste Bins / How many bins? / Yellow Recycling Bins / How many bins?
Any other council assistance/equipment:
Bollards
Community Event Ahead Signage
Speed Signage
Temporary Fencing / DETAILS:

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Risk Assessment FOR THIS EVENT (add more pages if required. See sample next page for examples)

If you have submitted a risk assessment for this event in previous years, you are able to use that assessment however it must be reviewed and updated where relevant.
Ref / The Hazard Category / Risk Identification
(Describe the issue in detail) / Level of Conse-quence / Level of Likelihood / Level of Risk / Treatment Option (s)
Describe the controls put in place
to reduce the risk
1
2
3
4
5
6
7

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SAMPLE Risk Assessment

Ref / The Hazard Category / Risk Identification
(Describe the issue in detail) / Level of Conse-quence / Level of Likelihood / Level of Risk / Treatment Option (s)
Describe the controls put in place
to reduce the risk
1. / Electrical Hazards / Faulty equipment, inappropriate setup of equipment/cords may result in electrocution or trip/fall injuries. / C3 / L4 / M / Council facilities are maintained to legislative requirements. RCDs are in place for all general outlets.Hire Agency to provide equipment. Council to provide power. Event Organiser to inspect cables and setup of equipment on site (ensuring all cords/cables are appropriately taped)
2. / Emergency Explosion/Fire/Bomb Threat / Large crowd will gathered in an enclosed area and potential for emergency situation to develop. / C3 / L5 / M / Emergency exit diagram provided at Council facility and fire emergency response equipment regularly maintained.
SAPOL and SA Police have been notified of the event. CFS officers will be attending (as civilians). First Aid people will be accessible.
3. / Trips/Slips/Falls / Large crowd with potential for spilt drinks. / C2 / L2 / H / Regular inspections are undertaken by Council. Stairs and walkways are well maintained by Council.
Bin facilities are provided for all drink containers. Designated clean up for any spills on the night. First Aid officer will be present.
4. / Hazardous Manual Tasks / Lifting and Moving Stage Equipment. / C3 / L5 / M / Mechanical lifting aid provided for larger equipment. No one other than specific person(s) will undertake hazardous manual tasks. First Aid officer will be accessible.
5. / Drug and/or Alcohol Related Hazards. / Patrons may arrive intoxicated or bring their own alcohol into the event. / C3 / L4 / M / Supervision and crowd control to be provided by security service. Responsible service of alcohol. Anyone found in possession of drugs to be removed from event. SAPOL have been notified of the event.
6. / Crime, Violence, Vandalism or Uncontrolled Crowd / Large number of young people present with potential for confrontation. / C3 / L3 / H / Supervision and crowd control to be provided by security service. SAPOL have been notified of the event.
7. / Access to Unauthorised Areas / Large crowds may try to access unauthorised areas. / C2 / L3 / M / Council have secured unauthorised areas with signage.Supervision and crowd control to be provided by security service.
8. / Proximity of Vehicles to Major Road / Large crowds attending event and designated car parking area is located across a major road from Council facility. / C5 / L5 / H / Supervision and crowd control to be provided by security service. The road speed is being reduced to 25km for the duration of the event with Council's prior approval and assistance.
9. / Food Poisoning / There is a risk that there is inadequate temperature control of uncooked and cooked food by caterer. / C3 / L3 / H / Council Environmental Health Officer has been informed of the event. Caterer’s are registered as food providers and have Food Business Notification Number. First Aid officer will be accessible.

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Analyse the Risks

Now that the risks have been identified the next step is to analyse the level of risk they present. Use Table 1 and Table 2 to determine the likelihood of it occurring and the consequence if it did. Then, use the consequence and likelihood ratings to determine the level of risk in Table 3.

Table 1 – Measures of consequences or impact

Level / Description / Example detail description
C1 / Insignificant / No injuries, low financial loss
C2 / Minor / First aid treatment, minor impact, medium financial loss
C3 / Moderate / Medical treatment required, moderate impact, high financial loss
C4 / Major / Extensive injuries, loss of production capability, major impact, major financial loss
C5 / Catastrophic / Death, detrimental effect, huge financial loss

Table 2 – Measures of Likelihood

Level / Description / Example detail description
L1 / Almost certain / Is expected to occur in most circumstances
L2 / Likely / Will probably occur in most circumstances
L3 / Possible / Might occur at some time
L4 / Unlikely / Could occur at some time
L5 / Rarely / May occur only in exceptional circumstances

Table 3 – Risk Analysis Matrix – Level of Risk

Likelihood / Consequences
Insignificant
C1 / Minor
C2 / Moderate
C3 / Major
C4 / Catastrophic
C5
L1 (almost certain) / M / H / H / E / E
L2 (likely) / M / M / H / H / E
L3 (possible) / L / M / H / H / H
L4 (unlikely) / L / L / M / H / H
L5 (rare) / L / L / M / M / H

Legend

E / Extreme Risk; immediate action required
H / High risk; senior management attention needed
M / Moderate risk; management responsibility must be specified
L / Low risk; manage by routine procedures

(Risk Management Standard AS/NZ 4360:2004)

General Conditions

The Event Organiser agrees to indemnify and to keep indemnified the Council, its servants and agents and each of them from and against all actions, costs, claims, damages, charges and expenses whatsoever which may be brought or made or claimed against them or any of them arising out of or in relation to the event.
Event Organisers are required to have a current Public Liability Insurance Policy for ten million dollars ($10,000,000) covering their activities on Council premises and ensure that all participants have a current Public Liability Insurance Policy or are specifically covered by the Event Organiser’s Public Liability Insurance Policy.
The Event Organiser or any other participant, where appropriate, shall ensure that it is licensed or registered to carry out the activity authorised by the event approval.
The event approval is not transferable and sub-rental by Event Organisers is prohibited.
The Event Organiser shall comply with and give all notices required by any Act of Parliament, Ordinance, Regulation or By-law relating to the activity or venue.
Council may revoke this event approval if the Event Organiser fails to comply with any of these General and/or Special Conditions or in any other justifiable circumstance.
Approval of the event will not come into operation until proof of all required documentation has been provided and approval issued.
Full payment of fees is due and payable on invoice from Council.
The premises shall be kept in a clean and tidy condition at all times to a standard satisfactory to Council. Should the premises not be returned to a clean and tidy state, the hirer will be called back to complete. Should this not occur, additional cleaning costs will be charged accordingly (hourly rate for cleaner) and recovered from the Event Organiser.
The Event Organiser is liable for damage, vandalism, alterations and loss to the facility which is caused or contributed to by the participants or guests of the event. Should loss of condition or items; or damage to the facility occur, the Event Organiser will be notified to either:
a) make good the loss or damage,
b) be responsible for the cost of Council making good the loss or damage or;
c) be responsible for the payment of Council’s insurance excess if the loss or damage exceeds Council’s excess amount.
Noise level shall be controlled and excessive noise prohibited. All music played must be kept to a level that avoids disruption to nearby residential areas.
No smoking is allowed in any Council building or within 10 metres of any open door or windows.
When leaving the facility please ensure that you secure the building doors, windows, etc.
The Event Organiser must report to Council all hazards, incidents involving a person or property damage at the facility as soon as possible by phoning 88426400.
Any electrical equipment brought onto the facility must be appropriately tested and tagged by a certified person.
No internal changes, renovations or additions are to be made to Council facilities without the prior written approval of Council.
Event Organisers must familiarise themselves with the items listed below when arranging the event at this facility and advise those attending the event of the following:
Safe access and egress points;
Emergency exits and external assembly point;
Emergency contact numbers;
In case of fire call 000;
Fire extinguishers and fire protection equipment (eg. hose reels and fire blankets).
The erection of signage or banners must be within the Clare & Gilbert Valleys Council area only.
Signs/Banner(s) MUST NOT obstruct vehicle or pedestrian traffic
Signs/Banner(s) MUST NOT be mounted to trees
Signs/Banner(s) may be mounted to existing posts if the location is suitable
Signs/Banner(s) must be safe and secure at all times
Signs/Banner(s) must be professional in appearance
Air holes may be required to reduce wind loads
Event Organiser is responsible for the signs/banner(s) at all times
Any signs or banners which present a hazard to the public will be removed by Council without notice
Council may decline an application if multiple signs are already in place
Public Notification
If deemed appropriate or necessary, Council may require the event organiser to undertake public notification of the event
This could be in the form of letter drops to nearby or affected residents, public notices in local media, evidence of consultation with local businesses or advanced warning signs to be displayed on roads that will be closed
Evidence of any such consultation will be required
Formal Development Application is required and Special Public Notification procedures need to be undertaken for certain events.
The special event will not be held over more than 3 consecutive days; and
In the opinion of council, an event of similar or greater, or of similar or greater impact on surrounding areas, has not been held on the same site within the preceding six months.

Special Conditions

Council officers will determine if any special conditions are required and note here.
Pre-event considerations:
During event considerations:
Post event considerations:

The approval of this event is subject to

1.The Event Organiser agreeing to all General Conditions contained herein.
2.The Event Organiser agreeing to all Special Conditions contained herein.
3.The Event Organiser paying the prescribed fee.
4.The Event Organiser providing alldocumentation as required in the application.
This approval is not transferable and may be revoked in writing at any time.

Event Organiser Declaration

I acknowledge that I have read and understand the approval conditions and agree to abide by the said conditions.
I confirm that all participants are adequately insured through their own public liability insurance policy or covered by the event organiser’s public liability insurance policy.
Signed for and on behalf of the Event Organiser
Name and position / Signature / Date

Council Authorisation

/ Office Use Only
Officer ApprovalSignature / Date

Road Closure Approval

/ Office Use Only
Traffic Management Plan and Road Closures approved by Council at its meeting held on

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